本帖最後由 lsc0019 於 2009-4-6 20:39 編輯
作者：Nick Mulcahy
出處：WebMD醫學新聞
March 20, 2009 (佛州好萊塢) — 加州洛杉磯、希望之城醫學中心的腫瘤醫師Robert J. Morgan在國際綜合癌症網絡(NCCN)第14屆年會中表示，藉由手術適當減積的卵巢癌病患中，應考慮使用一個腹膜導管進行後續的化療。
他在發表更新版NCNN卵巢癌指引時表示，就我看來，這是指引的重大改變之一。腹膜內導管可以讓病灶區域有更多直接給予的化療藥劑，在一篇研究中，可改善第三期卵巢癌病患的整體存活達到約67個月，而靜脈治療的病患只有約50個月。
Morgan醫師表示，另一個重大改變是，疑似有無法切除的殘留病灶之第二、三、四期卵巢癌的初級治療。
新指引呼籲這些病患先接受探知手術，之後進行化療；在化療之後，醫師應考慮再度手術，稱為完成手術。完成手術可以包括移除第二個卵巢或者輸卵管。
他表示，在最初的三到六個療程化療之後，醫師應考慮進行完成手術。此方法的最後一步是，在完成手術之後，進行六到八個療程的化療。Morgan醫師相信，這是合理的選擇。
討論末期卵巢癌之化療與手術的時機時，Morgan醫師引用治療期中減積手術這個爭議性方法的新資料，NCCN並未建議此一方法。
藉由治療期中減積手術，在進行第一次的減積手術之前給予新輔助化療；接著，在手術之後給予額外的化療療程。
Morgan醫師表示，這種末期卵巢癌的治療方法成為2008年末國際婦癌協會年會報告後的封面新聞。該研究中，治療期中減積手術在整體死亡率上有可和標準預先手術方法相媲美的結果，當時由Medscape Oncology報導。期中方法會有較少的殘留腫瘤與較少的併發症。
Morgan醫師表示，因為該研究未發表，NCCN委員會還未加以考慮。不過，他向Medscape Oncology表示，他料想該資料不足以令NCCN修改指引。他的理由有部份根據第三和四期病患(歐洲與加拿大)在期中減積手術和預先手術兩組中，平均整體存活均大約為30個月。他指出，美國此類病患採用預先手術時的平均整體存活約為50個月。
【處理過敏反應：對卵巢癌的特別考量】
今年的新版指引中，還有一段有關化療過敏反應處置的更新段落。所有化療病患都有過敏風險，但是那些再度治療者的風險更高。Morgan醫師表示，卵巢癌病患更應考慮過敏反應，因為70%至80%的晚期卵巢癌會復發，且許多病患需再度進行化療。
他表示，和多數癌症病患不同，卵巢癌病患通常需要再度進行化療。這類病患需考慮可能發生過敏反應，例如表皮、心血管、呼吸道、胃腸道、神經/肌肉事件等。
因此，他表示，可能需要減敏策略，特別是目前對復發卵巢癌最有效的白金製劑。
在討論他的減敏方法時，Morgan醫師建議腫瘤內科醫師對於再度使用白金製劑的病患，從緩慢輸注小劑量靜脈化療藥劑開始，然後慢慢增加劑量。
【有關臨床發現的新指引】
Morgan向聽眾表示，90%的初期卵巢癌可以治癒。不過，他也提醒他們，大多數卵巢癌病患在被發現時已經是第三期和第四期了。
在卵巢癌指引這一段中，輸卵管癌、以及原發性腹膜癌重疊，現在已經加入描述這些癌症症狀的敘述。除了腹部可疑的可觸及腫塊，臨床表現也包括鼓脹、骨盆痛或腹痛等症狀、進食困難或者很快感到飽足、以及泌尿系統症狀(急尿或頻尿)、但無其他明顯惡性來源。
他表示，現在認為有90%的卵巢癌婦女有這些症狀，對這些普遍症狀要有警覺。他解釋，所有婦女都有這些症狀，但是關鍵在於突然發作且頻率約為一個月內有12次。
Morgan醫師是Abbott Laboratories的股東。
國際綜合癌症網絡(NCCN)第14屆年會。發表於2009年3月14日。
NCCN 2009: Guidelines for Ovarian Cancer Updated
By Nick Mulcahy
Medscape Medical News
March 20, 2009 (Hollywood, Florida) — In ovarian cancer patients who have been optimally debulked through surgery, a peritoneal catheter should be considered in the administration of subsequent chemotherapy, said Robert J. Morgan, MD, a medical oncologist from the City of Hope, in Los Angeles, California, here at the National Comprehensive Cancer Network (NCCN) 14th Annual Conference.
"In my opinion, this is 1 of the major changes in the guidelines," he said while presenting the updated NCCN guidelines on ovarian cancer. The intraperitoneal catheter allows for a more direct administration of chemotherapy to the area of disease and, in 1 study, improved overall survival among stage?III ovarian cancer patients to about 67 months, compared with about 50 months among those treated intravenously, he explained.
Another "major change" is in the primary treatment of stages II, III, and IV ovarian cancers with suspected unresectable residual disease, said Dr. Morgan.
The new guidelines call for these patients to undergo exploratory surgery first and then chemotherapy. Clinicians should consider resurgery, known as completion surgery, after the chemotherapy, he said. Completion surgery can involve the removal of the second ovary or the fallopian tube.
"Clinicians should consider completion surgery after an initial 3 to 6 cycles of chemotherapy," he said. The last leg of this approach is the chemotherapy that follows the completion surgery, and that finishes the suggested total of 6 to 8 cycles. "This is a reasonable option," Dr. Morgan believes.
In discussing the timing of chemotherapy and surgery in advanced ovarian cancer, Dr. Morgan introduced new data about a controversial approach known as interval debulking, which is not recommended by the NCCN.
With interval debulking, neoadjuvant chemotherapy is administered before the primary treatment of surgical debulking; then, additional cycles of chemotherapy are delivered after surgery.
This method of advanced ovarian cancer treatment became front-page news after a report from the International Gynecologic Cancer Society meeting in late 2008, said Dr. Morgan. In the study, interval debulking had comparable results, in terms of overall survival, to the standard upfront-surgery approach, as reported by Medscape Oncology. The interval method may lead to fewer residual tumors and fewer complications.
Because the study is unpublished, the NCCN committee has not yet considered it, said Dr. Morgan. However, he suspects that the data might not be impressive enough to alter NCCN guidelines, he told Medscape Oncology. His reasoning is partly based on the fact that median overall survival in stage?III and IV patients (in Europe and Canada) was about 30 months in both the interval-debulking and upfront-surgery groups. Median overall survival in the United States in these patients is about 50 months when they are treated with upfront surgery, he noted.
Managing Allergic Reactions: Particular Concern in Ovarian Cancer
Also new to the guidelines this year is a section on managing allergic reactions to chemotherapy. All chemotherapy patients are at risk for allergic reactions, but there is a higher risk among those who are retreated. Allergic reactions are especially a concern among ovarian cancer patients because 70% to 80% of later-stage ovarian cancer will recur and many of those patients are retreated with chemotherapy, said Dr. Morgan.
"Unlike most cancer patients, ovarian cancer patients are often retreated with chemotherapy agents. There are a considerable [number] of allergic reactions to chemotherapies [in this setting]," he said, adding that the reactions include cutaneous, cardiovascular, respiratory, gastrointestinal, and neurological/muscular events.
As a result, "desensitization strategies" may be required, he said, especially with platinum drugs, which are "still the best drugs for recurrent ovarian cancer."
In discussing his desensitization methods, Dr. Morgan advised medical oncologists to start off with a slowly infused small dose of intravenous chemotherapy in patients being retreated with platinum agents, and to increase the dose slowly.
New Guidelines on Clinical Presentation
Dr. Morgan told the audience that "90% of low-stage ovarian cancers can be cured." However, he also reminded them that the vast majority of ovarian cancer patients are detected at stages?III and IV.
In a section of the guidelines where ovarian cancer, fallopian tube cancer, and primary peritoneal cancer overlap, a description of symptoms that are indicative of these cancers has been added. In addition to a suspicious palpable mass in the abdomen, the clinical presentation also includes "symptoms such as bloating, pelvic or abdominal pain, difficulty eating or feeling full quickly, and urinary symptoms (urgency or frequency) without another obvious source of malignancy."
"It's now thought that 90% of women with ovarian cancer will have these symptoms," he said, adding that he was aware of their ubiquity. "All women have these, but the keys are that there is a sudden onset and the frequency is about 12 times a month," he explained.
Dr. Morgan is a shareholder in Abbott Laboratories.
National Comprehensive Cancer Network (NCCN) 14th Annual Conference. Presented March 14, 2009. |
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